Mammography Screening for Transgender Male-to-Female Individuals
Transgender women who have received feminizing hormone therapy for 5 or more years should undergo screening mammography starting at age 50, with biennial screening being the most appropriate approach based on current guidelines.
Risk Assessment for Transgender Women
Transgender women (male-to-female individuals) have a unique breast cancer risk profile that differs from both cisgender men and cisgender women:
Studies show transgender women receiving gender-affirming hormone therapy have:
Risk factors specific to transgender women:
- Duration of feminizing hormone therapy (estrogen exposure)
- Family history of breast cancer
- Genetic predispositions (BRCA mutations, Klinefelter syndrome)
- Other conditions associated with high estrogen levels (liver disease, obesity) 1
Screening Recommendations by Professional Organizations
Several professional organizations have established guidelines for breast cancer screening in transgender women:
- Fenway Health: Annual screening mammography starting at age 50 for transgender women with ≥5 years of hormone therapy 1
- UCSF Center of Excellence for Transgender Health: Biennial screening mammography starting at age 50 for transgender women with ≥5 years of hormone therapy 1
- Endocrine Society: Screening similar to cisgender women (starting at age 40) 1
- American College of Radiology:
- Patients aged ≥40 with ≥5 years of hormone treatment: screening mammography or digital breast tomosynthesis may be appropriate
- Higher-than-average-risk patients: screening mammography or digital breast tomosynthesis are usually appropriate 1
Screening Algorithm for Transgender Women
For transgender women with ≥5 years of feminizing hormone therapy:
- Begin screening at age 50 with biennial mammography
- Consider earlier screening (age 40) if additional risk factors present
For transgender women with <5 years of hormone therapy:
- No routine screening recommended unless additional risk factors present
For transgender women with higher-than-average risk (family history, BRCA mutations, prior chest radiation):
- Begin screening at age 25-30
- Annual mammography or digital breast tomosynthesis 1
Important Considerations for Clinical Practice
Breast development in transgender women on hormone therapy results in breast tissue histologically identical to cisgender female breast tissue 2
Exogenous estrogen exposure increases breast cancer risk, as demonstrated in studies of postmenopausal cisgender women 3
Screening adherence is a significant concern - studies show mammography rates in transgender populations are significantly lower than institutional and national rates for cisgender patients 4
Digital breast tomosynthesis may be particularly valuable for transgender women, as it can visualize lesions that might be occult on standard mammography 2
When evaluating pathologic nipple discharge in transgender women, diagnostic imaging is appropriate regardless of age or duration of hormone therapy due to the high incidence of cancer in this presentation 1
Pitfalls and Caveats
Avoid assuming all transgender women have the same risk profile - consider individual factors like duration of hormone therapy, surgical history, and family history
Be aware that current guidelines are based on limited data with inconsistent hormone dosing and relatively short follow-up periods 1
Recognize that screening adherence may be affected by healthcare access barriers for transgender individuals 5
Do not assume that transgender women who have not undergone hormone therapy have the same risk as cisgender men - other risk factors may still warrant screening 1